pharmacy manual - almadallah.ae · difference in claimed amount and approved amount - more than aed...

Almadallah Providers Manual – Version06 – May, 2018

P

Almadallah Healthcare Management FZ LLC P.O. Box

478803 Dubai International Academic City Building No. 3,

Office No. 8 Dubai, United Arab Emirates

P

Almadallah HealthCare Management

PHARMACY MANUAL

Version 6 – May 2018 i

The revised edition of Almadallah Healthcare Management Pharmacy Manual is

intended to provide necessary assistance to our healthcare providers with

valuable information. The goal of this document is to give a broad overview of

the main function of pharmacy network providers conferring to terms and

polices of the contractual agreement set forth and in accordance to DHA/HAAD

guidelines.

Every effort has been made to ensure that this manuscript is an accurate

representation of the functionality of Almadallah Healthcare Management as

Third Party Administrator (TPA).

We make every effort to ensure the delivery of quality healthcare services to our

members through circumspect selection of Almadallah’s network healthcare

providers.

The general objective of these pharmacy manual is to standardize the provision

of clinical pharmacy services, thereby optimizing patient outcomes by ensuring

the rational use of medicines.

Preface

Version 6 – May 2018 ii

ALMADALLAH CARD ........................................................................................................................ 1

PHARMACIES .................................................................................................................................... 2

APPLICABLE DENIAL CODES ........................................................................................................ 5

ALMADALLAH EXCLUSION LIST ................................................................................................... 6

Treatment ........................................................................................................................................... 6

Pharmacy Exclusions ......................................................................................................................... 7

Pharmacy items/medicines related to Diagnostic Procedure ............................................................. 8

ALMADALLAH PRE-APPROVAL PROCEDURES .......................................................................... 9

Pre-approval Procedure ..................................................................................................................... 9

CLAIMS SUBMISSION AND RECONCILIATION ........................................................................... 10

Claims Submission/Resubmission .................................................................................................... 10

Reconciliation .................................................................................................................................... 10

Claim Status ...................................................................................................................................... 11

CONTACT DETAILS ........................................................................................................................ 12

APPENDICES:

Appendix A – Almadallah Claim Form ............................................................................................ 13

Appendix B – Almadallah Pre-Authorization Form .......................................................................... 14

Appendix C – Online Directory ......................................................................................................... 15

Member Login .................................................................................................................................. 15

Member Utilization ......................................................................................................................... 15

Claims Report ............................................................................................................................... 15

Payment Details-Reimbursement .................................................................................................. 16

Reconciliation Report ..................................................................................................................... 16

Provider Login ................................................................................................................................ 17

Claims Report ............................................................................................................................... 17

Batches Received-Direct ............................................................................................................... 17

Appendix D – Almadallah Invoice Form .......................................................................................... 18

Appendix E – Almadallah Detailed Statement of Accounts Form ................................................... 19

Appendix F – Almadallah Reconciliation Report Form ................................................................... 20

Appendix G – Almadallah E-Statement .......................................................................................... 21

Appendix H – Almadallah Resubmission Report Form ................................................................... 22

Appendix I – Almadallah E-Claim Submission Guide ..................................................................... 23

FREQUENTLY RAISED MEMBER CONCERN .......................................................... ……….24

Table Of Contents

Version 6 – May, 2018

1

LOGO

ALMADALLAH CARD


2

1. Pharmacist should check the Almadallah card with drearily packed stamped

copy of the claim form and original prescription.

2. Pharmacist should verify the card for its validity, member category and for any

specific Indications/conditions. Please verify the member’s Almadallah card with other valid personal ID for Almadallah

members visiting your facility. For parents/guardian of minors/children members, please verify with their personal ID with the members’ ID

3. Confirm eligibility (e.g. network, validity) - Check eligibility through our

online portal by logging in www.almadallah.ae with provided login credentials

4. The Expiry Date is the date that the insured member’s policy benefits and

ability to receive direct billing services at your facility expires.

Cards for some self-funded schemes do not have an expiry date - Those

cards are valid for unlimited period unless advised otherwise

Cards with expiration dates

The expiry date is inclusive of the end date

For example: Expiry Date = 31-Dec- 2010

A consultation occurring on December 31, 2010 is inclusive up to 12 midnight

For chronic medications: when the prescribed period is beyond the expiration

date, Almadallah must be billed until the expiry date only. The rest of the

medicines have to be billed to the member directly.

Claims received by Almadallah relating to expired cards will not be paid and will

be the provider’s responsibility.

5. Coverage: Our members will have different coverage guidelines according to

the current group and categories:

Pre-approval is NOT required to VIP members, either for In-patient or

Outpatient Services. However, standard exclusions apply for all categories.

DUBAI GOVERNMENT MEMBERS:

Category VIP: General Network + (GN+) & DHA facilities

Category A: General Network + (GN +) & DHA facilities

Category B: General Network (GN) & DHA facilities

Category C: General Network (GN) & DHA facilities

Category D: Restricted Network (RN) & DHA facilities

PHARMACIES


3

Pre-approval indication applies to all member for applicable medical

services. Standard exclusions apply for all categories.

DUBAI HOLDING MEMBERS:

Category A: General Network + (GN+) & DHA facilities

Category 1: General Network (GN) & DHA facilities

Category 2: General Network (GN) & DHA facilities

Category 3: Restricted Network (RN)

*Category 4: Restricted Network 2 (RN2) / Health Maintenance

Organization (HMO)

*Medical services (including medications) more than AED 150.00 requires

pre-approval (except GP consultation) and referral letter from GP for

Specialist consultations

Insurance based policies as per Table Of Benefits/Almadallah Card

6. Verify that all fields in the Claim Form are properly accomplished:

ACCURATELY AND CLEARLY by healthcare providers.

7. It is the pharmacy personnel’s responsibility to check the member’s

card and complete any missing information in the Administrative part of the

Claim Form.

8. VIP cards: A card with category VIP printed on it means that the card holder

is a very important person and should be attended to immediately and with

special assistance. Pre-approval is NOT required for members with

Category A VIP or A V for neither In-patient nor Outpatient Services.

However, standard exclusions apply for all categories unless otherwise

specified.

9. Pre-approvals are valid for a maximum of 10 calendar days during which the

pre-authorized services should be rendered. If the service was not rendered

or if it was rescheduled for another day, then the same request has to be re-

approved unless otherwise specified for Insurance related claims

10. See Exclusions List & Pre-approval Indications per the Almadallah

Pharmacy Guide

Check if the prescribed medicines are excluded or require pre-approval

Pre-approval required for all Maternity prescriptions

Pre-approval required for all Dental prescriptions

Pre-approval required for all Optical Eye-ware


4

Any medication related to:

All In-patient admissions

All Daycare/short stay admission

Major and minor surgeries

All work-related injuries

Trauma cases (mentioning the history of the trauma is mandatory)

11. Please note that Pre-approval is required only in cases where chronic

medication is prescribed for more than 3 months’ supply or medications with

cost more than AED 2000, unless otherwise specified for Insurance related

protocols.

12. Dispense the prescription strictly according to the directions of the

physician and according to the Almadallah Healthcare Policy coverage.

Please refer to the Almadallah Pharmacy Guide.

13. For medications that are not authorized or excluded, 100% of all related

charges should be collected from the patient after applying the agreed upon

Network Discount.

14. For eligible/authorized cases, any applicable co-participation amount, after

applying the discount, must be collected from the patient and the eligible

remainder should be billed to Almadallah.

15. A copy of the prescription can be provided to the patient upon request.

16. Medications that are not medically necessary, not medically appropriate,

not related to diagnosis and medications not prescribed by the treating

physician are not coverable.

17. Almadallah Healthcare Policy covers 2 weeks Home Nursing as per the

treating physician’s medical report. Pre-approvals are required for all

Homecare Nursing Pharmacy related services.

18. Drugs not available in DDC list can be approved and added to list by

sending to pharmacist in-charge


5

APPLICABLE DENIAL CODES ON PBM/PRIOR REQUEST CLAIMS:

1. Drug Duplicate Therapy – As per DHA guidelines whenever medication falls

under duplication - Service is not clinically indicated based on good

clinical practice (MNEC-003)

2. Drug to Disease Contraindication - As per DHA guidelines contraindication

between drug to drug and drug to disease - Service is not clinically

indicated based on good clinical practice (MNEC-003)

3. Difference in claimed amount and approved amount - less than AED 1.00 -

Calculation discrepancy (PRCE-001)

4. Difference in claimed amount and approved amount - more than AED 1.00 -

Submission not compliant with contractual agreement between provider

& payer (CLAI-012)

5. Service not indicated - Service is not clinically indicated based on good

clinical practice (MNEC-003)

6. Service requires Medical report attachment - Service is not clinically

indicated based on good clinical practice, without additional supporting

diagnoses/activities (MNEC-004)

7. Duplicate Service - Claim is a duplicate based on service codes and

dates (DUPL-001)

8. Quantity claimed by provider is more than to be - Service/supply may be

appropriate, but too frequent (MNEC-005)

9. Service Exclusion - Service(s) is (are) not covered (NCOV-003)

Denial Codes applicable if necessary:

Co-participation not collected from patient/member (COPY-001)

Discount discrepancy (PRCE-011)


6

A. Treatment Exclusions

1. Developmental delays

2. Learning disorders

3. Attention deficit disorders

4. Eating disorders

5. Anorexia

6. Obesity (unless mentioned otherwise)

7. Vaccinations except for newborns in the 1st 3 days of life + Tetanus & Anti-

Rabies in case of infection (only under DHA)

8. Infertility

9. Fertility

10. Sexual dysfunction

11. Sterility

12. All Preventive care

13. Check-ups including well baby check-up

14. Work permit related health screening except for the Antenatal screening

tests

15. All LASIK services & procedure

16. Plastic, Cosmetic surgery & treatment including any non-medically

necessary nasal surgery, unless relating from an accident which occurs after

the first enrollment date under the policy

17. Substance abuse

18. Addiction or Alcoholism

19. Radiation contamination

20. Professional sports injuries & not job-related sports

21. Hair loss, Dandruff, hair transplant , hair disorder

22. Home visit except in the case of emergency i.e. life threatening condition

and /or requiring inpatient admission

23. Genetic engineering and cloning

24. Diseases designated by the WHO as epidemic

25. Organ donation

26. Orthodontist services

27. Services or treatment in a long term care facility rehabilitation center, spa,

hydro, rest care, sanatorium, home care, nursing home for the aged, periods

of quarantine and or isolation.

28. Ambulance services Except transfer patient from home to hospital in

emergency case only & body of the patient who has expired from hospital to

home

ALMADALLAH EXCLUSION LIST


7

29. All Alternative Medicine such as but not restricted to : Acupuncture,

Acupressure , Osteopathy ,Chinese Medicine, Chiropractic, Cupping Therapy,

Homeopathy, Naturopathy , Ozone Therapy, Ayrovudics, Chiropody, Herbal

Therapy ,Reflexology, Aromatherapy, Hypnotherapy, Apitherapy,Colonic

Cleansing, Color therapy, Gemstone Therapy, Holistic Health, Iridology, Breath

Work, Kinesiology, Body Work, Buteyko, Flower Essences, Polarity Therapy,

Therapeutic Touch, Yoga, Crystal Therapy, Orthomolecular Medicine, pranic

Healing, Radionics, Therapeutic Humor, Traditional medicine, Herbal medicine,

Nutrition medicine, Anthroposophical Medicine, Music Therapy, Ear Candles,

Light Therapy, Magnetic Therapy, Massage Therapy, Qigong, Reiki,

Counseling Therapy

B. Pharmacy Exclusions

1. Fertility, Infertility related medicines/agents

2. Sexual dysfunction medication

3. Sunglasses, contact lenses solutions and accessories (unless otherwise

specified)

4. Appetite stimulants, appetite suppressants, dietary preparations

5. Oral hygiene, non-medicated lozenges, oral sprays dental and gum related

medicines and products, etc.

6. Contraceptive medicines and products

7. Cosmetic products, lotions, moisturizers, sunscreens, skin-lightening

agents, masks, face , cleansers, antiseptics, alcohol, etc.

8. Anti-oxidants, liver tonics

9. Oral rehydrating solutions between the ages of 10 – 65 years old

10. Soaps, shampoos, cleansers

11. Hair and scalps preparations

12. Routine vaccinations /Immunizations. Except for neonatal in the 1st 3 days

of life or until discharge

13. Vitamins, minerals and supplements, except those prescribed in adjunction

with anti-biotic, prescriptions to treat vitamin deficiencies (e.g. Resulting

from Anemia, diabetes)

14. Smoking cessation, substances abuse medication

15. Pain balms, rubefacient joint maintenance products and non-medicated

preparations

16. Crepe bandages, disposables, glucose strips, lancets

17. Castor oil, cod liver oil, clove oil, Eucalyptus oil, karvol ,etc.

18. Diaper/Nappy rash cream, formula, baby supplies

19. Artificial tears, liquifilm, dura tears, normal saline for patients over the age

of 10 years

20. Homeopathic preparations, preventive medicines, except those in the MOH

list as listed in the Al Madallah pharmacy Guide

21. Medications that are not medically necessary, not medically appropriate,

not related to diagnosis and medications not prescribed by the treating

physician


8

22. Immunomodulator drugs and/ or immunotherapy treatment unless

medically necessary

Basiliximab

Daclizumab

Rho (D) immune globulin

Methyl Prednisone

Mycophenolate mofetil

Sirolimus

Cyclosporine

Tacrolimus

Azathioprine

Etanercept

Infliximab

• Biological response modifier



• Glucocorticoid

• Immunomodulator

• Immunomodulator

• Immunomodulator

• Immunomodulator

• Immunomodulator

• Rheumatoid arthritis drug

• Rheumatoid arthritis drug

C. Pharmacy Items/Medicines Related to Diagnostic Procedures

1. Fertility, Infertility related tests and procedures

2. AIDS/HIV Related tests and procedures (including pre-operative) except

in antenatal maternity checkup)

3. Preventive tests and checkups

4. Screening tests and procedures (except for Maternity, please refer to

Maternity Protocols at the end of the Manual)

5. Employment related check-ups

6. Any tests not prescribed by a medical doctor licensed by MOH/DHA and

not under the Almadallah Network

7. Any tests related to excluded consultation

NOTE: Other Treatment/Medication can be covered in some cases for

certain group or members unless otherwise specified for Insurance

related protocols.

Please inquire to Call Center for more information (and request

for pre-approval if necessary)


9

PRE-APPROVAL PROCEDURE

APPLICABLE TO ALL CATEGORIES EXCEPT CATEGORY VIP

Pharmacy items/medicines under pre-approval list:

a. Pharmacy items/medicines listed under pre-approval indications require

Verbal Pre-Authorization to be obtained by calling Almadallah at 04-

5591322 or submitting request for approval through DHPO for

DHA/MOH Hospital and Al Shafafiya Portal for HAAD providers.

b. Register the name of the person granting the approval and proceed with

dispensing the item/medication. The Verbal Pre-authorization form will be

e-mailed or faxed within 2 hours. Kindly provide correct fax numbers

to prevent discrepancies.

c. The Claim Form, Verbal Pre-authorization Form and Invoice/s SHOULD

be attached when submitting Claims for payment.

d. To avoid duplication, kindly refer to eRx Claims Submission Guide (See

Appendix I, page 23)

PRE-APPROVAL PROCEDURES


10

A. CLAIMS SUBMISSION

1. Claims must reach Almadallah no later than 30 days (or as per contractual

agreement) from end of the month from date of service or patient discharge or

as indicated in the contract for eligibility of payment.

2. Submitted Claims should be clearly and completely filled and all relevant

supporting documents as medical report, results of all investigations done,

original prescriptions, discharge summaries (for In-Patient) must be attached.

3. Please submit each Batch of Claim Forms with the following:

a. The Original Itemized Invoice.

Kindly document and apply the % discount as per contract

on each Invoice

b. Detailed Statement Of Account.

4. Individual Claims (and accompanied documents) should be separated and

batched per Payer.

5. Each batch should be accompanied by Detailed Statement of Account Form

for that payer. The Detailed statement of Account should enlist the details of all

physical claims submitted for that particular payer within the allocated billing

period. (See Appendix E, page 19)

6. Payments are provided as per the terms of the Contract Agreement. Cheques

along with Payment Orders, Transaction Details and Batch Summary Report will

be provided.

B. PROCEDURE FOR RE-SUBMISSION

a) Re-submission should be made within 30 days (or as per contractual

agreement) of receiving the returned Claims or as per contract. Please

complete with Resubmission Form accordingly (See Appendix H, page 22)

b) Re-submit the missing documents as requested in the Reconciliation Report

and include a photocopy of the returned Claim Forms along with a copy of

the Reconciliation Report sent by Almadallah (See Appendix F, page 20)

CLAIMS SUBMISSION & RECONCILIATION


11

C. CLAIM STATUS (see Appendix C, page 15)

After evaluation, Almadallah can return/reject the claims due to the

following reasons as will be stated clearly on the Reconciliation Report

Form submitted at the time of payment:

Technical Denial: (Missing Document/s): Claim form along with all documents

will be returned back to the provider. One or more missing document/s are

required (reason for denial will be mentioned in the Reconciliation Report).

Partial Denial: Claim amount is partially denied as per policy terms and

conditions. A copy of Claim and documents will be provided with the Payment

Order. (reason for denial will be mentioned in the Reconciliation Report).

Full Denial: The claim amount is entirely denied as per policy terms and

conditions. A copy of the Claim and documents will be provided along with the

Payment Order. (reason for denial will be mentioned in the Reconciliation

Report).

Final Denial: These are denials after re-evaluation of re-submitted claims. The

decisions are final and re-submissions are no longer considered.


12

FOR PRE-APPROVALS

Call Center: 04-5591322 (24/7)

E-mail: [email protected]

FOR ADMINISTRATIVE ISSUES

[email protected]

FOR MORE INQUIRIES

Claims Submission/Resubmission or order claim form:

[email protected]

Clarification of Claims Rejections/Denials:

[email protected]

Network Inquiries: [email protected]

Account Inquiries: [email protected]

Website: www.almadallah.ae

Mailing Address for Claim Submission:

Almadallah Healthcare Management

P.O. Box: 478803.

Dubai International Academic City

Building 3, Office 8

Dubai, United Arab Emirates

CONTACT DETAILS

mailto:[email protected]






http://www.almadallah.ae/


13

Please Note: White Copy to be used by treating physician. Clearly mention

Providers name and include doctor’s stamp and signature. Yellow or Blue copy

can be used for either Pharmacy or Diagnostic/Laboratory procedures.

Patient’s

Details

Patient’s

Medical

History &

Diagnoses

Physician’s

Treatment Plan

& Prescription

Patient’s/

Guardian's

Signature

Appendix A


14

Appendix B

Please note: This form will either be emailed to the Provider as per Pre-

approval procedures on page 10

Pre-Authorization


15

Appendix C

Member Login:

Menus

Member Utilization

Claims Report

On-Line Directory


16

Payment Details - Reimbursement

Reconciliation Report (from above report as link)


17

Provider Login:

Claims Report

Batches Received – Direct


18


Invoice Form Provider’s Name: Patient’s Name:

Provider’s Address: Patient’s Card Number:

Provider’s Phone Number: Invoice Date:

Accountant: Invoice Number:

SN

Service

Code

Service

Description

Quantity

Gross

Amount

Discount

%

Discount

Amount

Patient’s Share Net

Amount Deductible Copay

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

TOTAL (AED)

NOTES:

Appendix D


19


Detailed Statement Of Account Batch # (for Almadallah use): Provider’s Name:

Total # of Claims Submitted: Name of Contact Person:

Billing Period: From: E-mail Address:

To: Telephone Number:

Submission Date: Fax Number:

SN

Date of

Service

Invoice

Number

Claim

Form

Number

Patient’s

Name

Gross

Amount

Discount

Amount

Patient’s Share

Net

Amount Deductible Copay

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

TOTAL (AED)

NOTES:

Appendix E


20

M –

Reconciliation Report

Batch #: Provider: Total Records:

SI Clai

m

No.

Invoic

e

No.

Patien

t/

Memb

er

Claime

d

Cost

Approv

ed

Cost

Denie

d

Amou

nt

Status Clai

m

Actio

n

Reque

st Form

No.

Remarks

( Report by : CLAIM)

Reconciliation Report Batch #: Provider: Total Records:

Bill

Ref.

Service

Price

Collected Service

Claimed

Service

Approved

Rejected

Status

Remarks

(Report by : BILL)

Technically Denied Medically Denied R - Rejected

Appendix F

Above reports are applicable for PHYSICAL claims submissions only

Kindly note the following:

A – Approved T –


21

Appendix G

E-Statement

Pro

vid

er N

am

e

Receiv

ed

Date

Serv

ice D

ate

Batc

h N

o.

Patie

nt

Card

No

.

Po

licy H

old

er

Su

bm

it/Resu

bm

it

Cla

im N

o.

InP

/ Ou

tP

Inv

oic

e N

o.

Bill N

o.

Serv

ice

Serv

ice C

laim

ed

Serv

ice A

pp

rov

ed

A

mo

un

t

Serv

ice R

em

ark

s

Den

ial C

od

e

Cla

imed

Am

ou

nt

Ap

pro

ved

Am

ou

nt

Reje

cte

d A

mo

un

t

ICD

/CP

T C

od

e

Rem

ark

s

Du

e D

ate

Su

rch

arg

e

Paid

Am

ou

nt

Paym

en

t Ty

pe

Paym

en

t Date

Paym

en

t Ref. N

o.

Ben

efic

iary

Paym

en

t Rem

ark

s

NOTE: E-Statement contains the following information:

Member’s/Patient’s Details are provide (i.e. name, card #, policy #)

Submission Type (submission[initial] / resubmission)

Claim Form Number

Batch Number

Visit Type (Out-Patient / In-Patient / Day case)

Service Rendered

Codes (ICD/CPT/ Denial codes)

Amount (claimed amount / approved amount / rejected amount / paid amount)

Surcharge applied (if requisite)

Payment Reference Number

Dates (received date / service date / due date / payment date)

General Remarks (for whole claim)

Service Remarks (reason of partial payment/rejection) – for easy compliance if eligible resubmission

is necessary) – KINDLY DO NOT RESUBMIT CLAIMS WITHOUT RECTIFICATION AND/OR

JUSTIFICATION

Kindly note that this information is being released to provider per each payment / batch /

cheque


22

Appendix H

PHYSICAL CLAIMS RESUBMISSION

E - CLAIMS RESUBMISSION

Resubmission Report In Reference To

Batch Number:

Provider’s Name:

SN Patient’s

Name

Card # Claim

#

Invoice

#

Claimed

Amount

Approved

Amount

Denied

Amount

Clarification for

Resubmission

1 ABC 1234 xxx 5678 160.90 100.00 60.90 Justification

2

3

4

5

TOTAL (AED)

NOTE: During claims resubmission, kindly attach the supporting documents (with the photocopy of claim form if required)

& copy of Reconciliation report sent by Almadallah

Claim

Ref

Card No.

Member

Service

Date

Claimed

Cost

Approved

Cost

Action

Resubmission

Type

Resubmission

Comments

xxx

1234

ABC

20 Jan

2016

160.90

-

Pending

Correction

Justification


23

Below are the details from the eclaimLink for eRx claim submission. As per DHA,

after getting the approval for the prior request, provider has to send eclaim for the

same for payment:

No. Transaction From To

Transaction submitted by the Provider/Clinician with the patient information and the

prescription details. Transaction validity is defined by the business rules.

1 eRx Request Provider/Clinician DHPO/eRx Hub

1.1 eRx Request DHPO/eRx Hub Payer/TPA

Transaction submitted by the payer in response to the e-Prescription

2 Prior Authorization Payer/TPA DHPO/eRx Hub

2.1 Prior Authorization DHPO/eRx Hub Provider/Clinician

Transaction to pull the e-Prescription details by the Provider/Pharmacy from the

DHPO/eRx Hub

3 eRx Request DHPO/eRx Hub Provider/Pharmacy

Transaction submitted by the Provider/Pharmacy requesting authorization for the e-

Prescription

4 Prior Request Provider/Pharmacy DHPO

4.1 Prior Request DHPO Payer/TPA

Transaction submitted by the Payer in response to the Provider/Pharmacy request

5 Prior Authorization Payer/TPA DHPO

5.1 Prior Authorization DHPO Provider/Pharmacy

Transaction submitted by the Provider/Pharmacy after dispensing the prescription

6 Claim Submission Provider/Pharmacy DHPO

6.1 Claim Submission DHPO Payer/TPA

Transaction submitted by the Payer in response to the Provider/Pharmacy claim

submission

7 Remittance Advice Payer/TPA DHPO

7.1 Remittance Advice DHPO Provider/Pharmacy

NOTE: Payer should receive the eclaim for the approved prior request for payment. E-claim submission is

related to the system used by the provider. When dispensing the drugs, if the internal system used by the

provider auto send eclaim, then the provider need not submit again as this will be a duplicate claim. If

not only, they should post it in DHPO.

Appendix I


24

- Member Eligibility to be checked on Almadallah Portal using the Card

Number or Emirates ID number at all times. If any issue, please contact our 24X7 Call Center 04 5591322.

- Inform the member correctly the reason of rejection (eg. Not covered, pending for more details, etc.).

- Please submit approval request on time in order to avoid delayed approval in order to avoid member waiting for long time for the procedures to be done.

- Kindly do not collect any deposit for any revised approval request from our member and follow contractual agreements as per approval protocols.

- Please submit the correct procedure/CPT request on DHPO in order to avoid any delay.

- Any service paid by member which falls under Exclusion List, kindly do

not advise our member to undergo reimbursement.

FREQUENTLY RAISED MEMBER CONCERNS

pharmacy manual - almadallah.ae · difference in claimed amount and approved amount - more than aed...

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